Improving Clinical Documentation for Heathcare Chaplains

Documentation is often seen as the bane of Chaplains who work in clinical settings, especially hospitals and hospices. I know when I first started I had no idea what most of those medical signs and symbols meant. I still remember early on in my career putting my hand up to ask our reporting nurse what she meant when she said our patient had a “cabbage” (hint: it’s a CABG, or coronary artery bypass graft). While it can draw a chuckle at team it can also be very intimidating to wander from our world of Greek exegesis into a land of vague Latin contractions and abbreviations.

Our documentation, while not the best part of what we do, may be the only way that others see what we are doing and how it is helping. Therefore it is extremely important to do a good job with our documentation to make sure that it is clear, concise and relevant. It’s not an easy job, and one that we rarely get any consistent schooling in. It’s also the area that most of us get dinged on first when it comes to chart reviews and professional supervision. The Association of Professional Chaplains offers it’s own guidelines regarding standards regarding reporting and documenting care. The APC states that Chaplain documentation should include the following:

While the what to include is more clear, exactly how to document this information is much more vague. In my time as a Chaplain I’ve seen documentation that has ranged from being a couple semi-intelligible half-sentences to English lit compositions. The first is unacceptable in that it leaves out so much necessary information as to be basically useless. The second is unnecessary and a poor use of time, including so many details that the important ones are lost.

The key is to document smarter, not longer, and you chart smarter by being focused on their Plan of Care. Including things like what they were wearing and the appearance of the room may help “paint the picture” but unless those details help support your care plan or their diagnosis they are unnecessary. To say that Mr. Jones wore brown slacks isn’t helpful, but to say that his slacks were ill fitting due to weight loss is.

In my own charting I try and follow a simple formula which is probably similar to what you would use back in journalism class in school:

Who did you see (patient, family, staff)? Who did you talk to (include staff as this attests to cross-disciplinary support)?

What do you see? How does the patient appear (tired, weak, pleasant, thin, pale)? Are there any visual as well as verbal indicators of pain?

Why are you there? Is this a routine visit or an emergency? Is this an assessment? Were you consulted to visit for a reason? Is there a particular problem you are addressing?

What did you do? What specifically clerical services did you provide? What else did you do that is related to their plan of care goals and interventions (taking them outside, providing life review, discussion of moral or ethical issues)?

What do you plan to do next? Is a follow up call to family needed? Do goals or interventions on their Plan of Care need to be changed? Are other services or consultations needed?

Here are some more hints:

Avoid over-using abbreviations, and consider getting rid of them altogether. They can be confusing or taken out of context (does OT mean occupational therapy or Old Testament?). Follow your agency’s guidelines and also consult a reputable source like Cahaba regarding medicare-approved abbreviations.

Don’t try to diagnose psychological, emotional or physical ailments. Rather than say that your patient is depressed or anxious, say that they appear or express being depressed or anxious – trust me, there is a difference.

Especially if you’re in hospice, know your patients’ diagnoses, know what to look for in terms of decline and document it. Often our tendency is to try to highlight the positives, but in hospice it’s best to highlight the negatives. Your documentation makes a difference and can help keep a patient on service.

Remember that your documentation is ultimately your best evidence of what you do and the value you add to your patients’ and families’ lives, as well as to the team. Don’t think that it’s not as important as anything else you do.

I commonly come across practical problems like contacting a priest for sacraments, contacting local clergy, ensuing their on the list of patients to attend. Less practical problems include loss of meaning, depression, lack of religious supports, guilt and anxiety. I also will go with these same issues in family members as well. If there isn’t a “problem” per se, you can indicate that while still provide interventions like prayer, life review, scripture and so on. I found this presentation helpful as well: https://www.mohospice.org/wp-content/uploads/2016/01/Volpitto-Documenting-to-Dazzle.pdf

Examples of treatment plans for chaplains in different situations would be helpful – situations such as hospice, oncology, drug addiction, PTSD, suicide, mental illness in general, excessive religiosity, etc. I am OK with the analysis portion of a chaplain’s note but I struggle with the treatment plan.

I think how you do the care plan will depend a lot on the software you are using, unfortunately. I used one software package in the past that was a lot more open regarding what you could list as problems, goals and interventions. My current one is much more limited. In any of the situations you describe I think it would be important to list the concrete presenting problems or issues (anxiety, addiction, cancer diagnosis, depression) and then describe the spiritual concerns that you see that either are present or could be present. It definitely helps to give examples of how a person may be exhibiting symptoms related to those concerns and then base your goals and interventions accordingly. Here’s an example:

Pt was resting in bed at the time, presents as weak and very anxious, frequently tearful. Is new admission to SNF from rehab unit, was at home prior. Pt is very fearful of taking pills or eating as it makes her nauseous. He wants to go home and feels he is “in prison”, however his caregiver has significant health issues as well, including recent Dx of breast CA, and is unable to care for him in the home. She visits regularly but this seems to take a toll on her as well. Both identify as Lutheran in the past but now do not want to be affiliated with the “institutional church” as they had bad experiences in the past with churches that were prejudiced against Asians. Pt’s anxiety may be influencing her symptoms, especially acid reflux, nausea and vomiting; she may benefit from psychological support if available. Both are open to ongoing support. Pt denied fear of dying but is very sad and anxious about leaving her husband. Chaplain will visit 2-4xM +2prn initially to help address anxiety, provide pastoral and spiritual support. Will provide spiritual counseling to help address possible feelings of abandonment by God, feelings of guilt and generalized anxity. Will also offer sacraments as means of reconciliation, encourage engagement in religoius activities at the facility to further develop support network and encourage spiritual practice. SCB

thank you. I wanted to point out that “Entering the World of Charting and Spiritual Assessments” by Mary M. Toole, BCC wrote a very similar article. She is a staff chaplain at St. Francis Hospital in Roslyn, NY The National Catholic Chaplains Association had an entire training on the challenges of charting and spiritual assessment. Rev. Kevin Massey from Advocate Health Care and a Templeton grant titled “”What do I Do? Developing a Taxonomy of Chaplaincy Activities and Intervention for Spiritual Care in ICU Patients.” Chaplain Massey created a “Chaplaincy taxonomy”. All this is so helpful.